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How Two Practices Give Mental Health Care a Primary Care Home

With a nationwide shortage of nearly 3,400 psychiatrists to meet the country's mental health care needs, one emerging viable remedy is a model that incorporates the diagnosis and treatment of mild to moderate depression and anxiety into primary care practice.

This model is spelled out in an American Medical Association (AMA) STEPS Forward module that offers ambulatory care practices a detailed approach to mental health care that relies on the skills of a layperson trained to lifestyle counseling or a health professional—such as a registered nurse or social worker—who addresses issues relating to anxiety, depression, sleep disorders and social-service needs. Whether layperson- or clinician-based, the primary care practice contracts with a consulting psychiatrist, who can handle more complex mental health issues.

The module details five steps for integrating a behavioral health model into primary care practice:

Assess current needs and resources

Design a team-based care model

Train members of the primary care team

Implement the team-based behavioral health model

Monitor and improve processes

How is the model working? Two case studies
One program that has implemented this model is the University of Michigan, through its Tailored Mental Health Management Support for Primary Care (TAMMS) effort. TAMMS uses a care manager, who is usually a professional with a social work background. The care manager:

Triages patients to appropriate services

Provides short-term psychotherapy to patients with mild to moderate forms of depression

Followsup with patients to ensure efficacy of care

Identifies other resources available to patients

Refers more difficult cases to specialists, such as to the consulting psychiatrist with whom TAMMS contracts.

The care manager, in consultation with the psychiatrist, also apprises the primary care physician of patients' progress and the need for any medication adjustments and additional interventions.

Evidence of TAMMS' success, which receives both private and public support, is in its recent expansion. Initially implemented at two community and two university clinics, the program doubled in size last year. Plans are underway to secure funding for longer-term implementation and sustainability.

In the Boston area, Brigham and Women's Advanced Primary Care Associates has implemented a behavioral care model whose success is contingent on the careful coordination of three physician-led teams, according to clinic director Stuart Pollack, MD. On each of these teams, the gateways to mental health care are the medical assistants (MAs), who at the outset of each patient visit administer two standard screening tools, PHQ-2 and PHQ-9, to assess whether patients might benefit from behavioral health care.

If patients' scores on these tests indicate a certain level of depression, the MAs consult with their physician to assess whether social work intervention is warranted. If so, the social workers assigned to patients stay in touch with them throughout their course of care at Brigham, checking in with them during and between visits to the practice and regularly apprising both the primary care physician and consulting psychiatrist of patients' progress.

The psychiatrist is viewed as an essential team member and attends meetings of the practice.

Members of each of the three physician-led teams include a physician assistant, two MAs, a licensed practical nurse and a social worker. These three teams tap into the expertise of the consulting psychiatrist, as well as a pharmacist, nutritionist and nurse care manager, who are all on staff.

The STEPS Forward module also addresses questions such as whether behavioralists can be shared among multiple physician-led teams in a practice and recommends lifestyle-counseling training resources. The module may be completed for continuing medical education credit. The AMA's STEPS Forward collection features 43 practice-improvement modules. Several come thanks to a grant from, and in collaboration with, the Transforming Clinical Practices Initiative.